Toxic Nursing, 2nd Ed. Cheryl Dellasega

to the patient’s husband, who is standing near the room where his wife is being treated. “The ER nurses didn’t get most of the information we need. Now I’ll have to go through it all over again with you.”

      Tessa makes sure to tell the nurse manager what happened, along with complaining to the other L&D nurses about the ER’s “crappy” patient care. The next time there is a transfer, the ER nurse makes sure to be as rude as possible to Tessa, and a unit-to-unit “feud” develops between the ER and L&D.

      nurse leader insight

      Acting out feelings, even by one individual, rather than discussing problems openly is an indication of a team that is not functioning as a team—either on their own unit or between units. There are tension points in all jobs. Everyone has a responsibility to deal with conflicts in an adult manner, not display emotion as a child who throws a tantrum when she does not get her way.

      In a family-centered care environment, the patient comes first, not a staff member’s tension points. Judgmental behavior such as that displayed by Tessa communicates an “I don’t want to work here with these incompetent people” attitude. This in turn communicates to the patient and her husband that they are being cared for by an organization that does not value excellence. Otherwise, why would the hospital employ staff who do not know what they are doing? Tessa’s behavior puts everyone on the team and the organization as a whole at risk as the patient and her husband potentially lose confidence at a time when they need their confidence to be reinforced. Respect for patients and a willingness to make them the center of all services must be an organizational value that is reinforced in all interactions. To deliver anything less is a violation of the trust that an employer places with the employee and the consumer expects from those in which care is entrusted.

      What are the options?

      Tessa is clearly angry and out of control. She is displaying unprofessional behavior to her coworkers and to the patient and the patient’s husband. A staff member, manager, or supervisor needs to be brought into the discussion before the shift ends to review the outburst.

      With the support of the unit manager, the L&D staff must confront Tessa about the issue with the ER staff. This can be done in a small group discussion and then followed up in a larger staff meeting. In conjunction with the managers of each of the units, “lazy and sloppy” work must be identified and remedied in a businesslike manner. A review of patient-centered care must be reinforced with all staff understanding how this is translated in practice. Language such as “crappy” patient care is not to be tolerated, and Tessa must receive an unequivocal warning that such behavior has to stop.

      The unit, service, and organization as a whole must reinforce the values that are held. Policies, procedures, brochures, posters, and the strategic plan must reflect that patient-/family-centered care is the focus. This will serve to support staff in their work. In addition, such value statements can be used in disciplining Tessa for her behavior, thus keeping her personally accountable and the team accountable to each other to uphold these values every day as they partner with each other and with those who are served.

      –Nancy M. Valentine

      Tessa has been openly critical at transfers (or handoffs) from ER to the L&D unit. These complaints are well known to her peers, and she has come to the nurse manager with the latest incident. Her continual complaints may or may not be justified. However, Tessa was unprofessional verbalizing her complaint in front of a laboring patient’s husband.

      First, it doesn’t take much imagination to see a red-faced expectant father screaming at the ER staff after Tessa’s statement. After a full investigation confirms a public complaint to the patient and husband, a written reprimand should be privately issued to Tessa. This written reprimand should also include instructions on immediate cessation of public criticism of the ER to her peers or anyone other than the manager. ER communication at transfer after the incident is obviously strained. As the nurse manager, you will be the one to bring the ER and the L&D staff together by apologizing for Tessa’s behavior to the ER manager. This will begin to repair the breach to ensure professional communication is reinstated at transfer.

      Second, does Tessa know how to constructively present complaints up the chain of command? Have her previous complaints been met with resistance to address issues? Do her complaints have merit on transfers from the ER to L&D? Handling Tessa’s ongoing complaints constructively may reveal gaps in transfer. Ask her to bring solutions with her complaints. Determine if a transfer policy, procedure, or education is needed to meet the transfer needs of L&D and the ER. A new checklist that fairly addresses responsibilities between the ER and L&D on documentation and transfer to L&D may increase patient safety and decrease tension during handoff.

      Successful channeling of staff complaints may create quality improvement with other processes. In my research, I have found that nurses who file complaints and see no change become increasingly disempowered or disgruntled by lack of action on management’s part. Lack of trust in management related to poor follow-through on legitimate issues leads to silent resignation and disempowerment.

      As a nurse manager, are you listening? When a problem or complaint comes up, how do you inform your staff of your actions to correct the problem? Do you consider the psychosocial and physical safety of your nurses a priority, given that nurse job satisfaction is correlated to patient satisfaction?

      Are nurse managers the last to know? Yes, unless a nurse manager is on the floor on a continuous basis interacting with staff, conflicts and complaints can go unreported and unnoticed. This is because the culture has taught nurses to be silent to those in power. However, nurse managers need to promote expectations on open communication, encourage staff to bring solutions to address problems, and provide transparency with solving these complaints. The staff needs to know why issues can’t be resolved yet or will never be resolved.

      –Peggy Ann Berry

      reflections

      It’s so easy—in life and at work—to be critical of others. We sometimes think to ourselves: “If only I had been there, this could have been done right!” Yet there is so much we don’t know about the reality of the situation, because we weren’t there.

      When nurses are critical of others, what can you do about it? What are some reasonable steps to take to try to help the criticism-queen see that they might not have the complete story? If things progress further—into a feud—what strategies would you employ to try to mend fences with other units in your organization?

3.3 Anything You Can Do, I Can Do Better

      scenario

      Although Maureen has worked in the MICU for only two years, the other nurses refer to her as “super nurse.” The nickname isn’t meant as a compliment. “One time, I had just worked a double and had barely kept on top of my patients, who were both very unstable,” recalls Sandy, a long time MICU nurse. “When I was telling Maureen about it, she assured me that nothing could be worse than the time she worked a double and had two even sicker patients.”

      “Maureen actually did an online search and printed out information on this weird EKG pattern my patient had one day,” says Terry, another MICU nurse. “She kept insisting she was right, even though it was a transient arrhythmia with no associated symptoms. During shift report, she made sure to mention her superior knowledge and made me look stupid.”

      Maureen’s one-upmanship goes beyond her interactions with nurses. When physicians come into the MICU, she rushes to help them and makes sure they know how efficient and in control she is. None of her colleagues are quite as able or smart as she is—or so Maureen thinks.

      nurse leader insight

      The idea of a super nurse is a fantasy, as no one can “know it all” in today’s fast-paced healthcare scene. Moving into an established work team can be very difficult even for experienced nurses, and it is just that much harder for a younger, inexperienced nurse to find